E-drug: A Visit to India: Drug Prices, Research & Global Access
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I think that a number of our readers would be interested in these observations
Richard Laing
A Visit to India: Drug Prices, Research, & Global Access by David Scondras
January 1999
[Note: AIDS activist David Scondras is also a political and public-policy
expert, who served as an openly gay member of the Boston City Council for
ten years. Recently he returned from a 27-day trip to India, where he met
with researchers and officials on access to treatment, and on potential new
research on both modern and traditional medicine. He has established a
collaboration between the Boston based Search for a Cure organization and
the Parkash AIDS Foundation of Mumbai, which is hoping to provide antiviral
medicines manufactured in India to poor countries at cost. ]
* * *
On average, drugs manufactured in India are between 1,000 and 4,000 percent
cheaper than the same product in U.S. pharmacies. Drug companies have
pushed hard to stop India and other poor countries from making cheap copies
of their life saving medicines by including the curtailment of these
practices in the international trade agreement, the GATT [see "GATT and the
Gap: How to Save Lives," AIDS TREATMENT NEWS #307, November 20, 1998]. By
pushing for such international agreements on trade, public agencies and our
government become accomplices to stopping medicines from reaching the poor.
The costs of medicine depends on who makes it and where it is made. At the
Taj Mahal hotel in Mumbai (Bombay), you can buy Hytrin, a sophisticated
antihypertensive, for 7 cents a tablet. A month's supply of the drug costs
about $4.20. At a local pharmacy in Boston, the same drug from the same
company costs $44.48, more than ten times as expensive. And the Indian
price is marked up on the order of 200%.
In Boston, ranitidine (the generic equivalent of Zantac, an H-2 blocker
which helps you not make stomach acid) costs 42 cents for 150 mg. The same
exact product at the Taj costs less than 2 cents (1.79 cents). In other
words, even the cheap, generic equivalent in the U.S. is a mere 2246% more
expensive!
In fact, most drugs, including antiretrovirals, are very inexpensive to
manufacture. Their prices reflect what the market will bear, not what they
cost to produce. U.S. pharmaceutical firms buy the basic ingredients to
antivirals in bulk from other countries at incredibly inexpensive rates.
For example AZT (zidovudine) in bulk can be purchased as of December, 1998
for 42 cents for 300 mg from the worldwide suppliers; this price reflects
not only the profits to the manufacturer but also to the middleman bulk
buyer. This drug is retailed at $5.82 at my local (CVS) pharmacy. This
means that tableting, packaging, marketing and transporting of the
medicine, plus profit, adds 1285% to the basic price, already excessive.
This ridiculous price cannot be justified except in terms of what the
market will bear, as it bears no real relation to cost of production. An
Indian company, Cipla, based in Mumbai, sells AZT in capsule form for $1.42
per 300 milligrams, and according to local experts, Cipla is accruing 2-3
hundred percent profit margins with the drug. Yet they are selling it at
less than a quarter of the price in the U.S.A.! This price could be reduced
significantly more if the drug were packaged by India's state owned
pharmaceutical firms.
To provide antiretrovirals to the world, there would have to be a paradigm
shift in our collective decision making processes. There are choices. All
of them are in the arena of public policy, not medical research. Under the
present paradigm, governments have to either pay for extremely expensive
drugs at very high prices and distribute them to the South [developing
countries], ignore the 95% of the world that cannot afford these costs, or
take actions that would bring down the costs of the drugs. And before the
creativity that might solve this public policy dilemma can be unleashed,
there would have to be an underlying shift in will--a paradigm shift in
which saving the developing world from unnecessary illness and death
becomes a priority over short term economic gains. Thus far, each
alternative has been politically too costly. There are efforts being made
but they are far too small even conceptually to put an end to a world of
untreated disease.
Treatable AIDS-related illnesses will not end until medicine is made
available to everyone who needs it. And this requires an imaginative
reshaping of the political and economic decision making
paradigms--primarily a reshaping that moves us away from a system which
defines values in terms of short term gains and takes a longer view of self
interest. For in the end, a world full of disease is bad for business.
Family Values and Science
We have designed a world in which profitability determines what will happen
and what will not. Our religious and community values stress integrity,
compassion toward those who are suffering, delayed gratification, honesty,
sharing of resources, cooperation, collaboration, and working toward the
common good. But our economic system stresses entirely contradictory
values--self reliance, independence, competitiveness and immediate
gratification. Our economic system does not allow much effort to be
expended on research that will not have an immediate financial
payoff--either because the people affected are too poor to constitute a
market for end products, or because the people affected are too few to pay
for the costs of the research. This is appropriate for the private
sector--but for Government to stop acting as a compensating force,
balancing the need for short term gain with the need for long term
investment in the environment, in public health, in education, in economic
stability, and in protecting society from social instability by providing a
minimum degree of access to basic services for everyone--for Government to
stop playing this role spells disaster for the world community.
Our inability to stop the HIV epidemic and its myriad of problems reflects
more than the limitations of science. It reflects the results of a cultural
shift during the latter half of this century toward a value system that
equates worthwhileness with money. Ignoring this is to mis-identify the
cause of many HIV treatment problems in both the North and the South. In
fact, many public health problems are the direct result of a system that
has slowly drifted toward using short-term financial gain as its only
measure of value.
In the South, this measuring stick has led to a variety of obstacles and
inequities--among them, the drug cocktails that only a very few very rich
people can afford. In the North this measure short changed what science
could have provided; the primary reason so little is known about drug
combinations and side effects is the same reason drugs are not available at
all in the South.
For example, data now suggests that certain old antiretrovirals used
together can be as powerful as the famous protease-inhibitor-based drug
cocktails. Had we known this when they were first approved by the FDA, we
could have saved many lives. But the drugs were made by different companies
and competition between them made it financially difficult for them to test
their products together. Who would be liable for any problems? How would
company secrets be kept? Who would benefit if the combination proved
successful? Who would pay for it? These questions discourage collaborations
between companies. The obvious long term scientific benefits are
overshadowed by the key question of short term financial benefit to the
stockholders of the companies involved.
Interestingly, an effort was made in the midst of the HIV epidemic to form
a collaboration of private companies. It still exists, known by its
acronym, the ICC (Inter-Company Collaboration for AIDS Drug Development),
and it is trying to undertake joint efforts. Unfortunately, it has tended
to prove the difficulty of making this research system work. Its very
failure, in efforts that have been without question supported at the
highest levels of each company, underlines the difficulty inherent in
collaborative efforts between competitors in a market-driven context.
Thomas Kuhn long ago identified the key elements of successful scientific
inquiry. He identified the success of science as dependent upon a central
value: communality. This value holds that all truth must be accessible to
everyone so that science can build upon everyone's work. To have anyone
withhold or add conditions would eventually lead to many doing so,
effectively stifling the growth of knowledge.
The key value of communality, however, fits poorly into corporate culture.
Communality holds that all information about any subject of inquiry is to
be shared with everyone. This runs completely counter to patenting and
protecting discoveries, or worse, keeping them secret from everyone except
those who need to know within a company.
We have engendered a culture that increasingly values nothing but money and
its accumulation. Our public actions increasingly serve the money-making
activities instead of controlling and balancing them with regulations and
investments in the public interest. So the use of old drugs in combination
to control HIV was not developed. The private sector did not look at the
combination, because there was no likelihood of immediate financial return
to a specific company, and there were serious legal, marketing, and other
problems in cross-company collaboration.
The only other actor that could have checked out the combination was the
federal government. But there was no agency empowered to find a cure to
HIV--to cut the red tape, to put in place strategic plans, to force
collaboration or to follow anything but academic whims and hunches that
make up the basis of the efforts of the only U.S. agency directly empowered
to find answers: the National Institutes of Health.
As a result many thousands of people have died and thousands more have used
up the effectiveness of these drugs in the less useful context of
sequential monotherapies. Who knows how many mothers, fathers, sisters and
brothers of the rest of the world have died at the hand of this new god.
It is often pointed out that at the time 'we did not know better'. However,
had our decision to stop HIV followed a strategic plan analogous to our
effort to put someone on the moon, there is no question but that the value
of using drugs in plausible combinations would have been investigated
immediately. Instead, we allowed the 'private sector' to dictate the agenda.
The profit motive has been a critical part of getting treatments developed.
Without it, much of the effort to locate compounds with antiviral potential
might not have happened so quickly. But, like all motives, it has
shortcomings. To not admit this and compensate for them in a coherent,
effective way is to burden the world unnecessarily.
The two worlds of North and South are under one god--and they suffer from
the limitations of that god. These result from the sociological shift from
the researcher as searcher of truth and the doctor as bringer of medicine,
to the researcher as part of drug development and the doctor as part of the
drug sales force. Most importantly, both reflect the role governments have
chosen: to facilitate the needs of the invisible hand that has reached the
status of a god, rather than analyze what the public needs, and temper the
god to serve our common interests.
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